It is increasingly recognised that patients are a source of reliable data on a range of issues, and healthcare complaints have been shown to reveal problems in patient care (eg, medical errors, breaching clinical standards, poor communication) that are not captured through the usual safety and quality monitoring systems. But patients and their complaints are an underused resource. Unlocking the potential of these complaints requires more than encouraging and facilitating complaints; it also requires systematic procedures for analysing them. The tools available for such analysis had a number of limitations, including that no established taxonomy for categorising healthcare complaints existed.

The researchers set out to develop such a taxonomy and create a tool to use it. They used lay participants to analyse complaints in terms of severity, with four levels of severity identified, and seven distinct categories of complaints: quality, safety, environment, institutional processes, listening, communication, and respect and patient rights.

The research started with a systematic review of 59 articles on health-care complaint reporting. From these articles, the researchers aggregated the coding taxonomies, revealing 729 uniquely worded codes, which were refined and conceptualised into seven categories and three broad domains. The domains were: clinical (referring to the behaviour of clinical staff and relating to the literature on human factors and safety), management (referring to the behaviour of administrative, technical and facilities staff and relating to the literature on health service management) and relational (referring to patients’ encounters with staff and relating to the literature on patient perspectives, misunderstandings, empathy and dignity).

The authors note that nearly one-third of healthcare complaints relate to the relationship domain. They also suggest that across these three domains, the tool they have developed can ‘bring into decision-making the distinctive voice of patients, providing an external perspective (eg, in comparison with staff and incidents reports) on the culture of health-care organisations’.

The researchers obtained, using a Freedom of Information request, a redacted random sample of the complaints received from 52 healthcare trusts during the period April 2011 to March 2012, which resulted in a dataset of 1082 letters (about 1% of the 107,000 complaints received by NHS Trusts during the period).

They tested the reliability of the tool being developed using educated, non-expert ‘raters’ (recruiting 14 participants with MSc-level psychology education) because complaints are routinely coded by educated, non-clinical experts. These ‘raters’ identified problems with the categories.

The coding used an iterative, multi-stage process. For example, they identified background details in each complaint (eg who made the complaint, and about whom), the stage of care (eg admissions, on the ward), and the severity, the latter using a five-point scale ranging from minimal harm (1) to catastrophic harm (5).

Examples of the coding of the letters are shown in Figure 2 below.

One of the innovative uses of the tool is that it can reliably code severity within each complaint category. Existing tools could only identify frequency of problems, thus penalising those organisations that proactively encourage complaints to improve quality. The authors suggest that the optimum complaint profile might be a high percentage of low-severity complaints, as this would demonstrate that the institution facilitates complaints and has managed to protect against severe failures.

Among the limitations of the new tool, the authors note that it did not include data from GPs, and as such some adaptation would be needed (although they recommend preserving the HCAT structure of three domains and seven categories). It would also be interesting to consider how such a tool could be adapted to other organisations and to government departments, to encourage analysis of complaints to improve service delivery and decision-making.

The researchers note that although ‘healthcare complaints are heterogeneous and require detailed redress at an individual level … complaints and associated severity levels can be reliably identified and aggregated. Although this process necessarily loses the voice of individual complainants, it can enable the collective voice of complainants to inform service monitoring and learning in healthcare institutions.’